PD VOLUNTEER APPLICATION

WAIVER OF LIABILITY AND RELEASE OF CLAIMS AND INDEMNITY AGREEMENT

I understand and agree that I am not an employee of the City and County of Broomfield and will not represent myself as such. I do hereby further understand and agree: 1. That I understand the activities included in this assignment. That I am aware that there may be certain risks involved in providing volunteer services for the City and County of Broomfield, said risks may include injury or accident to person or property or other loss, and I freely, voluntarily, and with such knowledge assume any such risks while volunteering my services. 2. That the City and County of Broomfield and its employees, agents and assigns shall not be responsible or liable for any injury damage, loss or expense, either to me or my property incurred while volunteering my services and resulting from any act or omission on the part of any employee, agent, or assign of the City and County of Broomfield. 3. For myself, my heirs, executors, administrators, and assigns, to defend, indemnify, release, and hold harmless, the City and County of Broomfield and all of its employees, agents, and assigns from and against any and all manner of actions, causes of actions, suits, debts, claims, demands, or damages, liability or expenses, including attorney’s fees, of every kind and nature incurred or arising by reason of any actual or claimed act or omission of mine while volunteering my services to the City and County of Broomfield, including, but not limited to, claims of sexual harassment, civil rights violations, or relating to alcohol or drug use. 4. That the City and County of Broomfield reserves the right to terminate me from my volunteer services, in its sole and exclusive discretion if my work is not satisfactory. 5. That the City has my permission to use for any purpose any photographs, videotapes, recording or any other record which may contain pictures or recordings of me participating in this volunteer program. 6. That the information in this volunteer application is true and complete. I understand and agree that false statements, misrepresentations or omissions of information in this application may result in rejection of this application. The City and County of Broomfield is expressly authorized to investigate all statements contained in this application. Further, I understand and agree that volunteer service is conditioned upon the successful completion of an investigation into my background. I hereby authorize the City & County of Broomfield to conduct such background investigation, including consumer reports which may include, but are not limited to, social security number verification, criminal background check, and sex offender registry check; and a driving record check and computer voice stress analysis test, if applicable. I hereby consent to the release of information about my ability and fitness for volunteer assignment by employers, schools, law enforcement agencies, and other individuals and organizations to investigators, personnel staffing specialists, and other authorized employees of the City and County of Broomfield. I understand and agree that I may be disqualified from further consideration should I fail any of the testing or background processes 7. That in the event that I am selected to become a volunteer for the City and County of Broomfield, I agree to comply with all of its ordinances, rules, and regulations. I fully understand and agree to provide my services to the City and County of Broomfield as a volunteer in a voluntary capacity and that I will receive no compensation or benefits for services provided, and that I am NOT subject to any of the provisions of Title 2 of the Broomfield Municipal Code regarding Personnel Administration. 8. That I am NOT insured by Worker’s Compensation Insurance. I understand and agree that I am covered by an Accident Medical Insurance Policy, only as a secondary or excess insurance policy that only insures me to the extent I am not otherwise insured by Medicaid, Medicare, or any group or individual insurance policies. I understand and agree that said secondary insurance provided by said Accident Medical Insurance Policy is subject to the limitations of coverage in that policy, including the limits of coverage of $25,000 per loss that is reported within 30 days of the date an injury is incurred. I understand and agree that said secondary insurance policy is available for my review in the Human Resources Department. I accept this secondary insurance policy as the limit of City and County liability while I am a volunteer with the City and County of Broomfield. I understand and agree that if I choose to transport program participants in any private vehicle, that I must maintain current automobile liability insurance coverage on said vehicle, in accordance with statutory requirements. The City and County will not provide any automobile liability insurance coverage for said purpose or said vehicle or be responsible for any liability or claim arising there from. 9. I acknowledge it is my responsibility to be sure that my emergency contact information is current. In the event of any emergency, I authorize the provision of medical treatment deemed necessary for my immediate care from any licensed hospital, physician, and/or medical personnel, and I agree that I will be responsible for payment of any and all such services rendered. I hereby represent that I have carefully read and understand the contents of this document and sign the same of my own free will.*

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Is the applicate under the age of 18?*

NO YES

PARENT OR LEGAL GUARDIAN CONSENT (IF VOLUNTEER IS UNDER 18): I, the undersigned, do certify that I am the parent or legal guardian of the above applicant, that I have read and understand the above WAIVER OF LIABILITY AND RELEASE OF CLAIMS AND INDEMNITY AGREEMENT, and that I consent and agree to the terms stated therein. In the event that an injury or accident occurs while the above referenced applicant is volunteering, it shall be my sole responsibility to provide insurance coverage or guarantee of financial responsibility.*

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DISCLOSURE REGARDING PROCUREMENT OF A CONSUMER REPORT

Name*

First Name

Middle Name

Last Name

Phone*

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Date of Birth*

SSN*

(XXX-XX-XXXX) Format

In connection with your application for volunteer service with the City and County of Broomfield, we may procure a consumer report on you including, but not limited to, a social security number verification, criminal background check, and national sex offender registry, as part of the process of considering your candidacy as a volunteer. In the event that information from the report is utilized in whole or in part in making an adverse decision with regard to your potential volunteer service, before making the adverse decision, we will provide you with a copy of the consumer report and a description in writing of your rights under the Federal Fair Credit Reporting Act. The Fair Credit Reporting Act (FCRA) gives you specific rights in dealing with consumer reporting agencies. You will be given a summary of these rights together with this document. The terms “consumer report” and “credit reporting” in this document are for the specific purpose of informing you of your rights under the FCRA. We use an outside agency only to conduct identity verifications, criminal background checks and sex offender registry checks. We do not conduct credit checks. By your signature below, you acknowledge receipt of the Disclosure to Volunteer Service Applicant Regarding Procurement of a Consumer Report and a Summary of Your Rights Under the Fair Credit Reporting Act and you hereby authorize us to obtain a consumer report about you in order to consider you for volunteer service.*

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A Summary of Your Rights Under the Fair Credit Reporting Act

The Fair Credit Reporting Act gives you specific rights in dealing with consumer reporting agencies. Below is a summary of your rights.

The federal Fair Credit Reporting Act (FCRA) is designed to promote accuracy, fairness, and privacy of information in the files of every consumer reporting agency (CRA). Most CRAs are credit bureaus that gather and sell information about you – such as – if you pay your bills on time or have filed bankruptcy – to creditors, employers, landlords, and other businesses. You can find the complete text of the FCRA, 15 U.S.C. §§1681- 1681u, at the Federal Trade Commission’s web site (http://www.ftc.gov). The FCRA gives you specific rights, as outlined below. You may have additional rights under state law. You may contact a state or local consumer protection agency or a state attorney general to learn those rights.
· You must be told if information in your file has been used against you. Anyone who uses information from a CRA to take action against you – such as denying an application for credit, insurance, or employment – must tell you, and give you the name, address, and phone number of the CRA that provided the consumer report.
You can find out what is in your file. At your request, a CRA must give you the information in your file, and a list of everyone who has requested it recently. There is no charge for the report if a person has taken action against you because of information supplied by the CRA if you request the report within 60 days of receiving notice of the action. You are also entitled to one free report every twelve months upon request if you certify: 1) you are unemployed and plan to seek employment within 60 days; 2)you are on welfare; or 3) your report is inaccurate due to fraud. Otherwise, a CRA may charge you up to eight dollars.
You can dispute inaccurate information with the CRA. If you tell a CRA that your file contains inaccurate information, the CRA must investigate the items (usually within 30 days) by presenting to its information source all relevant evidence you submit, unless your dispute is frivolous. The source must review your evidence and report its findings to the CRA. (The source also must advise national CRAs – to which it has provided the data – of any error.) The CRA must give you a written report of the investigation, and a copy of your report if the investigation results in any change. If the CRA’s investigation does not resolve the dispute, you may add a brief statement to your file. The CRA must normally include a summary of your statement in future reports. If an item is deleted or a dispute statement is filed, you may ask that anyone who has recently received your report be notified of the change.
Inaccurate information must be corrected or deleted. A CRA must remove or correct inaccurate or unverified information from its files, usually within 30 days after you dispute it. However, the CRA is not required to remove accurate data from your file unless it is outdated (as described below) or cannot be verified. If your dispute results in any change to your report, the CRA cannot reinsert into your file a disputed item unless the information source verifies its accuracy and completeness. In addition, the CRA must give you a written notice telling you it has reinserted the item. The notice must include the name, address and phone number of the information source.
You can dispute inaccurate items with the source of the information. If you tell anyone – such as a creditor who reports to a CRA – that you dispute an item, they may not then report the information to a CRA without including a notice of your dispute. In addition, once you’ve notified the source of the error in writing, it may not continue to report the information if it is, in fact, an error.
Outdated information may not be reported. In most cases, a CRA may not report negative information that is more than seven years old; ten years for bankruptcies.
Access to your file is limited. A CRA may provide information about you only to people with a need recognized by the FCRA – usually to consider an application with a creditor, insurer, employer, landlord, or other business. Your consent is required for reports that are provided to employers, or reports that contain medical information. A CRA may not give out information about you to your employer, or prospective employer, without your written consent. A CRA may not report medical information about you to creditors, insurers, or employers without your permission.
You may choose to exclude your name from CRA lists for unsolicited credit and insurance offers. Creditors and insurers may use file information as the basis for sending you unsolicited offers of credit or insurance. Such offers must include a toll-free phone number for you to call if you want your name and address removed from future lists. If you call, you must be kept off the lists for two years. If you request, complete, and return the CRA form provided for this purpose, you must be taken off the lists indefinitely.
You may seek damages from violators. If a CRA, a user, or, in some cases, a provider of CRA data violates the FCRA, you may sue them in state or federal court.

The FCRA gives several different federal agencies authority to enforce the FCRA:

For Questions or Concerns Regarding: CRAs, creditors and others not listed below Please Contact:


For Questions or Concerns Regarding	Please Contact:
CRAs, creditors and others not listed below	Federal Trade Commission Consumer Response CenterFCRA Washington, DC 20580 (202) 326-3761
National Banks, federal branches/agencies of foreign banks (word “National” or initials “N.A.” appear in or after bank’s name)	Office of the Comptroller of the Currency Compliance Management, Mail Stop 6-6 Washington, DC 20219 (800) 613-6743
Federal Reserve System member banks (except national banks and federal branches/agencies of foreign banks)	Federal Reserve Board Division of Consumer & Community Affairs Washington, DC 20551 (202) 452-3693
Savings associations and federally chartered savings banks (words “Federal” or initials “F.S.B.” appear in federal institution’s name)	Office of Thrift Supervision Consumer Programs Washington, DC 20552 (800) 842-6929
Federal credit unions (words “Federal Credit Union” appear in institution’s name)	National Credit Union Administration 1775 Duke Street Alexandria, VA 22314 (703) 518-6360
State-chartered banks that are not members of the Federal Reserve System	Federal Deposit Insurance Corporation Division of Compliance & Consumer Affairs Washington, DO 20429 (800) 943-FDIC
Air, surface, or rail common carriers regulated by former Civil Aeronautics Board or Interstate Commerce Commission	Department of Transportation Office of Financial Management Washington, DC20590 (202) 366-1306
Activities subject to the Packers and Stockyards Act, 1921	Department of Agriculture Office of Deputy AdministratorGIPSA Washington, DC 20250 (202) 720-7051